In the following summary, the main causes for non-exclusive or shorter-than-desirable breastfeeding are listed.

Problems with the initiation of breastfeeding lower breastfeeding rates

In some EU countries only about 50% of mothers initiate breastfeeding. Even where initiation rates are higher and approach 100%, many mothers experience breastfeeding problems during the first few weeks, such as breast and nipple pain and complications, due to lack of knowledge and little self confidence, and inadequate support for good positioning and latching. Moreover, many first-time mothers do not know what to expect, how much time and dedication a baby needs, and tend to give up unless adequate support is available. Low initiation rates and high incidence of initial problems are typical of bottle feeding cultures. The first measures, therefore, are the development of national and local policies that present breastfeeding as the natural choice, to increase the rate of initiation, and that provide adequate initial support. Such support is best provided by maternity services that apply the Ten Steps for Successful Breastfeeding of the Baby Friendly Hospital Initiative.

Good initiation alone, however, is insufficient. Support for the continuation of exclusive breastfeeding up to six months is also necessary. Baby Friendly primary and community health care services with supportive and competent health workers and/or peer counsellors, are essential to ensure adequate continuation of breastfeeding. For more details see The Seven Steps for the Protection, Promotion and Support of Breastfeeding in Community Health Care Settings. Mothers of preterm and sick infants, who may benefit even more than healthy term infants from exclusive breastfeeding, need special support at both hospital and community level.

Early use of formula or other breast milk substitutes also lower breastfeeding rates

One of the main causes of non-exclusive or shorter-than-desirable breastfeeding is the early and inappropriate use of formula or other breast milk substitutes. This is often the effect of aggressive marketing of these products by manufacturers and distributors. In 1981, to reduce this effect and protect breastfeeding, WHO and UNICEF adopted the International Code of Marketing of Breast Milk Substitutes (WHA, 1981). The Code has since been updated regularly by relevant Resolutions of the WHA. The EU Directives that transposed the International Code into EU and national regulations in 1991 and 2006 (EC, 1991; EC, 2006b), fall short of the minimum requirements recommended by the Code. More rigorous regulations need to be adopted and enforced to protect breastfeeding in the EU.

Need to return to work and inaccurate advice lower rates between 4 and 6 months of age

Exclusive and non-exclusive breastfeeding rates tend to fall, among infants who continue breastfeeding, between 4 and 6 months. This is often due to inaccurate advice mothers get from health professionals and lay people, including relatives and friends. Another common reason is the need for many mothers to return to an active work life (Hawkins et al., 2007). These two problems obviously require different solutions.

The provision of inaccurate advice can be tackled by equipping health professionals and other people giving advice to mothers with better knowledge and skills, while a mother’s need to return to an active work life can be overcome with better social protection for working mothers (Galtry, 2003; Staehelin et al., 2007). Better social protection may include allowing working mothers who wish to breastfeed as recommended to do so by extending the time of maternity leave to six months. Afterwards, working times could be made flexible, with so called breastfeeding breaks to either breastfeed if the child is nearby or pump and store breast milk for later use. Workplace crèches or similar arrangements should be set up whenever possible, and adequately equipped. Maternity leave and breastfeeding breaks should be extended for mothers of twins and preterm or sick infants. Better social protection for working mothers has been shown to be beneficial to overall child health, in addition to breastfeeding (Tanaka, 2005).

Fear of environmental contaminants in breast milk may stop mothers from breastfeeding

Breast milk is often used to detect persistent residues of man-made chemicals that accumulate in human bodies; this applies in particular to fat soluble substances, such as dioxins and PCBs, because of the high fat content of breast milk. These contaminants can enter the body through ingestion, inhalation and skin contact, and pose a definite risk to the foetus. The fear that this will occur may also stop some mothers from opting to breastfeed. All the organisations using breast milk to monitor levels of environmental pollutants, however, stress that their purpose is not to harm breastfeeding and emphasise that the advantages of breastfeeding are not compromised by any potential risk from residues of these contaminants in breast milk. Research has also shown that the presence of these environmental contaminants in breast milk is not associated with health risks; on the contrary, breastfeeding appears to reduce or revert the damage caused to the newborn by the exposure to the same contaminants during pregnancy (Ribas-Fito et al., 2003).

Alcohol and substances derived from smoking, as well as drugs such as heroin, cocaine and amphetamines, are also passed to the infant through breast milk, and directly through passive and non-passive smoking, and may harm its health (see the EUphacts Alcohol use, Smoking and Drug use for more detailed information) (Howard & Lawrence, 1998; Little et al., 1989). The use of these substances should be discontinued during pregnancy and lactation, or at least reduced to a minimum. Individual counselling should be available to assist parents to make appropriate decisions. If an occasional alcoholic drink is consumed, breastfeeding should be avoided for two hours afterwards (Mennella, 2001).